GMS/DVC Repeat Prescription Request | baltinglassfamilypractice.ie

First Name *

Last Name *

Date *

Email Address *

Phone Number *

Full Address *

Eircode

GMS/DVC Card Number *

GMC/DVC Card Expiry Date *

Medication (include name of medication, dose, irritant) *

Usual GP* *

Nominated Parmacy *

Checkbox *I understand that if I do not have a valid Medical, DV Card my prescription request will not be processed.I consent to my prescription being sent digitally from the practice to my chosen pharmacy.I acknowledge that it takes up to 48hours (excluding weekends) to process repeat prescriptions.I consent to this message being sent electronically to teh practice. I have chaked the th eemail address and phone number supplied are correct and consent to receivingmedical information via email or text.

Note

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